Why Residents Are Vital To Successful High-Value Education Projects

Christopher Moriates, MD is a Clinical Instructor in the Division of Hospital Medicine at the University of California San Francisco (UCSF). He is currently Co-Chair of the UCSF DHM High Value Care committee. During residency training he co-created a cost awareness curriculum for residents at UCSF. 

I learned a lot of medicine during residency, but perhaps I actually learned even more about how to just get things done in a hospital. If you wanted a right-upper-quadrant ultrasound done for our patient, I was your man. I had a complicated series of unwritten algorithmic flow diagrams in my head that included handwriting an order, making sure that it was faxed to the right number, calling the appropriate person to get a technician if it was afterhours, and knowing who to call for the preliminary results.  These were all dependent on the day of the week, time of day, and whether we were at UCSF, San Francisco General Hospital, or the V.A. Sound ridiculous? Yes, it was.

Trust me, though, these broken systems are not unique to our medical center. Consider, the following analogies from the brand new Institute of Medicine report:

• “If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records.
• If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.
• If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all.”

Yes, ridiculous, indeed.

I have been out of residency now for exactly 87 days, and everything has changed. A new computer system has been implemented at our hospital and a whole new crop of interns - like Magellan chartering the Atlantic to the Pacific for the first time - are boldly routing out their own new process maps for countless different scenarios.

As an attending, my new formula (thankfully) looks like this:

“Need ultrasound done -> Ask intern.”

I am already woefully out-of-touch.

My point is, if you want to know about all of the waste in the system, the crazy things that we do that don’t make any sense, the countless middlemen and non-value-added steps, and the overtreatment and excess testing that lead to harm for patients, then you need to ask a resident on the “frontlines.”  And, you know what? Not only do they intimately know about these areas of nonsense, but it drives them the most insane!

This is because this pervasive waste in medicine is disrespectful not only to the patients that we inflict it on, but also to our medical professionals whose time is squandered maneuvering through meaningless steps.

At a recent national meeting, the question was raised by a medical educator, “But how do we try to implement “Choosing Wisely” or “Lean” initiatives when we have trainees at our medical center?”

The question should not suggest how do we achieve these goals despite trainees, but rather how do we do this with trainees. No, take it even a step further. How do we get our trainees to show us how to best incorporate a “Choosing Wisely” philosophy?

Let’s consider this illustration. As a third year medicine resident, I was the primary “champion” for our new Cost Awareness curriculum at UCSF. Frankly, my colleagues were rooting for me to succeed. Now, the questions posed at the conferences by residents after we “opened up Pandora’s box” of cost consciousness were not necessarily easy – I don't think that many punches were pulled by some who were uncomfortable talking about hospital charges for the first time, or reviewing cases that showed our excesses. But the majority buy-in and enthusiastic support of the residents for a project by one of their own was likely a powerful strength to our successful launch.

My fellow residents stopped me in the wards to tell me “how proud” I would be of them for… talking their intern through not getting that unnecessary chest CT scan, or stopping the repeat blood cultures within 72 hours for their patient with fever, or… on it went. This curriculum and movement was something that we were doing together, not something being done to us.

So, what can departments and residency programs do to help facilitate residents’ involvement in these sorts of projects?

1. We can provide the scaffolding necessary for success. The first time I wrote up a formal educational needs assessment, or gave a noon conference, or spoke at a scientific meeting, I needed faculty mentors to help guide me through the process. With this sort of backbone support I was able to climb so much higher than I would have on my own. To help catalyze this process, programs can actively identify and match residents with appropriate mentors who are experienced in Quality Improvement and/or Value projects.

2. We can do what Dr. Talmadge King, Chair of Medicine at UCSF, did recently and explicitly state that “Choosing Wisely” is a priority of our department. This means a commitment to put some of our support, time and resources behind these types of projects and educational initiatives.

3. We can specifically carve out time for residents to pursue, achieve and present these projects during their residency. I mind you, not in spite of their patient care training, but in line with it. Many programs already do this for traditional research projects. We need to create an environment where these new types of projects are valued as academic contributions to our institutions.

4. We can help obtain and share data about costs, charges and variation at our own medical centers. For many this information is impenetrably, and unreasonably, hidden and opaque. We need help from the top to get access to this data.

 5. And if all else fails, we can do what we always do in medicine to convince people that this is a worthy cause. We can quote Sir William Osler: “Medical care must be provided with the utmost efficiency. To do less is a disservice to those we treat, and an injustice to those we might have treated (1893).”

“Go Ask Your Doctor…” – Educating Patients and Physicians About Costs of Care

Christopher Moriates, MD is a Clinical Instructor in the Division of Hospital Medicine at the University of California San Francisco (UCSF). During residency training he co-created a cost awareness curriculum for residents at UCSF and is an active member of the American College of Physicians (ACP) High-Value, Cost-Conscious Care Curriculum Development Committee. 

The New York Times said that I probably should skip my annual physical. The other day, Consumer Reports sent me something in the mail entitled, “Imaging tests for lower-back pain: Why you probably don’t need them.” It said that imaging is “often a waste of money” and raised concern about cancer resulting from the radiation. They also published an article subtitled “Learn when to say ‘Whoa!’ to your doctor.” The ABIM Foundation’s widely publicized “Choosing Wisely” campaign popularizes lists of various practices that “physicians and patients should question.”

Instead of “Go ask your doctor if Cialis is right for you,” may we actually start to see patients asking their doctor if they really need that test or procedure? Will patients themselves help curb health care waste? Well, you may say that I’m a dreamer, but I’m not the only one.

If you are a physician, you probably should be thinking about how the heck you are going to appropriately field these questions, while crossing your fingers that the patient doesn’t actually go so far as to ask you how much that medication or test is going to cost them (the illustration of the doctor taking a stab in the dark is just about right).

After all, this was likely never even on the radar during your training. Admittedly, some prominent folks in medicine question whether it even should be, as nicely shown in this brand new, balanced article in the New England Journal of Medicine, which also highlights the Cost Awareness curriculum that we (Drs. Krishan Soni, Andrew Lai, Sumant Ranji, and myself) have developed here at UCSF, and the inspiring work of Dr. Neel Shah and the Costs of Care organization.

Given all of this, I strongly argue that it is becoming increasingly obvious at this point that physician education is going to be a key “necessary, but non-sufficient” initial intervention in approaching high value care.

I will reappropriate an analogy that Bob Wachter, UCSF Chief of the Division of Hospital Medicine (and my new boss), quoted to our group today about a slightly-different, but related situation (paraphrased): “The medical world has one foot in the boat and one foot on the dock and pretty soon is going to need to decide to jump in the boat. It is pretty clear where the boat is going.”

Enter the new AAIM-ACP High-Value, Cost-Conscious Care curriculum, which officially launched just days ago on July 10, 2012. Some of the resources, including the successful case-based format and take-away lessons, from our UCSF Cost Awareness curriculum, were adopted and adapted for this exciting new curriculum. This AAIM-ACP ten-module series is freely available to anyone interested (with the completion of a very short registration form) at www.highvaluecarecurriculum.org.

The curriculum, developed under the leadership of Dr. Daisy Smith from the ACP, by a committee including Internal Medicine program directors, faculty and residents from around the country, consists of ten one-hour interactive sessions (an overview of this curriculum is provided). The modules are organized around real-life inpatient and outpatient cases including estimates of hospital charges. It is meant to be flexible enough to fit into different resident structures, such as morning report, noon conference, post-clinic conferences, or academic half-days.

I encourage you to go check it out.

Go ask your Program Director or Chief Resident if the high value care curriculum is right for you.  

Side Effects May Include Financial Ruin

Christopher Moriates, MD is a senior resident in Internal Medicine at the University of California San Francisco (UCSF). He is a co-creator of a cost awareness curriculum for residents at UCSF and is currently working with the American College of Physicians (ACP) on their national “High Value, Cost Conscious Care” curriculum. 

He winced in a way that made me feel his discomfort. It wasn’t overly dramatic; it was a response of a man trying to put on a brave face and hide his pain, but - as I gently laid my hands on his belly - failing against his best efforts. This man had real abdominal pain, the kind that is impossible not to immediately empathize with. I got concerned.

“How long has this been going on?” I asked, while my mind began to immediately tick through a differential diagnosis.

“Well it probably started a year ago, but got really bad about four months ago,” this otherwise healthy-appearing, thirty-something-year-old man said.

We were in a small curtained-off area in the hectic Emergency Department at San Francisco General Hospital (SFGH). I started to wonder what in the world would possibly cause somebody to wait many months with severe abdominal pain and rectal bleeding before coming to see a doctor.

I asked a few more questions, verifying that he was indeed having bright red blood with his bowel movements, had lost at least 10-pounds over the last few months and has dealt with nausea and debilitating abdominal pain ever since the end of last year.

So, I pulled out one of my most tried-and-true questions that I have picked up during residency:

“What made you come to the hospital today as opposed to yesterday or last week?”

The answer should have surprised me.

“Well, I didn’t want to see a doctor because I couldn’t pay for it. I had to wait until my benefits kicked in so that I had insurance.”

The Emergency Department had already put him through the CT scanner prior to calling me to admit him to the hospital, in order to ensure that he “didn’t have something really bad going on,” which I have to admit that if you had put your hands on his abdomen you would probably think was a more reasonable (if not very eloquently phrased) concern. 

The CT scan showed inflammation of his colon in a pattern that the radiologist said was very likely Crohn’s Disease.

His lab tests returned with severe anemia (hemoglobin of less than seven) and an undetectable iron level, revealing that the bleeding had been going on for a long time. I told him that I thought he needed a blood transfusion and a colonoscopy procedure in the morning by one of our gastroenterologists.

Then he asked me one of my most feared questions that I have picked up during residency:

“But how much will that all cost and will my insurance pay for it?”

“I wish that I could answer that for you, but I really don’t know.”

Now, the thing is that I actually have spent more than the past year working on cost awareness for residents and looking into issues related to costs of care, and even I couldn’t answer this question in a straightforward and truthful manner. This man needed these things done and costs be damned. Sure, but let’s be honest, his concern is very real. Medical bills are the leading cause for personal bankruptcy in the United States. And at his young age, the effects of an expensive inpatient work-up could be devastating for a long time to come. Incredibly, in 2007, 78% of filers of personal bankruptcy caused by medical problems had medical insurance at the start of their illness.

The best I was able to do was tell him that in my medical opinion he needed these procedures in order to make the diagnosis and get the right treatment for his disease. My medical training has taught me how to recognize inflammatory bowel disease, diagnose it and treat it, but it has not adequately addressed how to not inflict insurmountable financial harm on some of my patients in the process. To me, it is straightforward; this man needs medical treatment for Crohn’s Disease. To him though I may be replacing his abdominal pain with another debilitating problem.

This all seems especially unfair when just a few weeks ago we reviewed a case in our monthly UCSF Cost Awareness conference of an elderly man with a headache who was seen at our University-affiliated clinic across town from SFGH and underwent BOTH a negative head CT and a brain MRI and didn’t pay a dime – the outpatient MRI was “charged” on his bill at $3,644, of which Medicare paid the incredibly reduced “price” of $275 and Medi-cal picked up the $178 that the patient would have been responsible for.

The man’s headache, by the way, resolved with “meditation.” That’s probably a good prescription for all of us right now.